Case Study #1

Author: Lauren S. Schlesselman, PharmD

BB, a pharmacy student on
his ambulatory care rotation,
is approached by a
medical intern while
working in the clinic.
The intern explains that
he has a patient in a
treatment room who has
presented him with a problem that
he is unsure how to treat.

The patient is a 25-year-old woman who has recurrent vulvovaginal
candidiasis. She is not immunocompromised and
does not have uncontrolled diabetes mellitus. She had been
treating her infections with OTC products until 4 months ago.
At that point, she was so frustrated with the monthly infections
that she came to the clinic for help. The intern had given
her a prescription for 1 dose of oral fluconazole with "asneeded"
refills. The patient had used the fluconazole monthly
since then, but the infection rate had not decreased. Now
the patient would like to find a way to reduce the recurrence
of infections.

The intern could not find any information about treatment
options that would reduce recurrence. He wanted to find an
answer before he approached his attending physician so that
he could impress the physician.

Although they have not been validated with randomized controlled trials, BB can offer some therapies. Treatment should
include induction therapy for a minimum of 14 days or until remission is achieved. Standard doses of most OTC and prescription products
can be used as induction therapy, so long as they are continued for 2 weeks. Induction should be followed by maintenance therapy for 6
months. Maintenance therapy can include weekly vaginal clotrimazole, weekly fluconazole, daily ketoconazole, or monthly itraconazole.